Healthcare Provider Details

I. General information

NPI: 1063674893
Provider Name (Legal Business Name): BENNETT EDWARD MOEHL PSYD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/02/2008
Last Update Date: 03/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

91 NORTHWEST DR
PLAINVILLE CT
06062-1534
US

IV. Provider business mailing address

371 BREWSTER RD
BRISTOL CT
06010
US

V. Phone/Fax

Practice location:
  • Phone: 860-793-3500
  • Fax:
Mailing address:
  • Phone: 860-906-7006
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number StateNULL
# 2
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number003453
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: